A28 64�:�rson County Health Department
�Sewage System Improvements Permit
Date � S S �Z This Permit Void Afte'r+ -5 Years Permit #
Owner: ��'? Q Y�� ����l� ��� � 6.1�
Locadon/Direcdons:
SubdivisionName: ' ` Lot#�_ �
Lot Size: Type of Dwelling: ��c,� �
Water Supply: Private: —� Public: Community:
Bedrooms: Garbage Disposal
Basement Basement F' , ; �
INFORMATjki D BY ' S
SSilit2ti8r1: � o er a repmsenta v
REPAIIt: REEV UATION:
------------------------- �
Size of Septic Tank: gallons Size of Pump Tank:
Nitrification Line:
Depth of Stone: 12 inches
Max Depth of Trenches:
Altemative System: Conv. Pump ` LPP Pump
Remarks: _ 1 /3 , �� _ , � �1 /-�
- �-
---------- �-� �--��---t ----
Date Well Approved: Well should be 100 ft from any sewer system
BY Sanitarian
Date Sewage System Approved:
BY Sanitarian
CERTIFTCATE OF COMPLETION ,.,3
Contr�tor. �
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Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumpeci out every 3 to 5 years and shall be maintained
by owner in such manner as not to czeate a public health hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person Counry
Health Departrnent before any portion of the installation is covered and put into use. If
the site plans ar inter�deci use change this permit is subject to revocation.
(G.S. 130 A-335F)
Locadon of sewage disposal sewage system sketched on back.
(OVER)
NOTE: Make aketch of installation showing lot size and shape, location oi house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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Sitg Evaluation Application
Fee Collected YES +� NO
Date: � �� �� v
APPLICATION FOR IMPROVEMENTS PERHIT
1. Permit requested by: owner/prospective owner:
� agent:
Address:
Home Phone ��:
, t3usiness rnone �f:
2. Name and address of current owner:
3. Property Description: Lot size: .3l�� C_
4. Tax map ��: Township : ���y�- ,'�,
Subdivision Name: Lot ��:
5. Directions to property•p State Road �� & Road Names/, e�tc.
� �.� ��r� %� 0 c>,� ��2 ��2f1.s✓P � -� (/(i dr vi�3"�� nJ
6. Permit requested for: New Installation: �O Repair:
Additional Renovation re-using present system:
7. Number of occupants or people to be served:
8. Dimensions of Proposed Structure: Width: Depth:
�
10.
11,
What type (if any) additions, expansions, or replacement is anticipated to the struc-
ture or facility that this sewage disposal system is intended to serve?
Water supply private? J/ public? community? spring?
Other source? (Specify):
Are there any wells on adjoining property? � If so, identify location:
Type of structure or facility: Proposed: � Existing:
Type of dwelling: House: ✓ Mobile Home: Business:
Type of business: Number of Employees: ,
Number of bedrooms: Garbage Disposal? Yes No
Basement? Yes No If so, number of basement fixtures:
12. Clearly stake all corners of the property and the corners of all proposed structures.
I hereby make application to the Person County Health Department for a site
evaluation or existing system evaluation for the on-site sewage disposal system for
the above described property. I agree that the contents of this application are true
and represent the maximum facilities to be placed on the property. I understand if
the site is altered or the intended use changes, the permit shall.become invalid.
Permits are valid for 60 months from date of issue. Permission is hereby granted to
enter the property for the evaluation. G.S. OA 335(F)
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igned Owner or Authori ed Agent
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Permit Issued t�
Permit Denied
Plat Observed �
�ACTORS - SITE EVALUATION AREA 1 AREA 2 AREA 3 AREA 4
1. SLOPE (X)
2 . SGIL TEXTt1RE (12-36 i.n. )
(Sandy, loamy, clayey,
Note 2:l clay)
3.. SOIL STRUCT[TRE (12-36 in.
(Clayey soils)
4 . SOIL DEPTH (in. )
S. RESTRICTIVE HORIZONS (in.
(Im�ervious Strata. rock)
6. SOIL DRAINAGE/GROUNDWATEF
(FScternal & Internal)
7. SOIL PERMEABILITY
(Percolation Rate)
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9. SITE CLASSIFICATION
(See below)
SOIL SERIES
S- Suitable PS - Provisionally Suitable U- Unsuitable
R ECO2�R�NDATIONS / COt�iIIdTS :
S�TE CLASSIFZCATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies,
aet areas, fill,areas, wells, water bodies, slope patterns, etc.)
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